Local Health Department Accreditation Process and Benefits

1. Local Health Department Accreditation Process and Benefits Erin Mowlds, Program Manager for Local Accreditation Local Accreditation Webinar Series Coalition of Local Health Officials

2. Purpose & Objectives • Overview of basic accreditation concepts • Discuss the value of accreditation • Why Now? • Process for LHDs to become accredited • Staff Roles and Documentation • Role of QI in accreditation

3. What is accreditation? Public health department accreditation is defined as the development of a set of standards, a process to measure health department performance against those standards, and reward or recognition for those health departments who meet the standards. • A set of standards that assure high quality services, accountability and efficiency. • Consistent standards combined with strong accreditation process helps the entire public health system do better. • Most other government entities already go through accreditation

4. Public Health Accreditation Board (PHAB) • Non-profit entity formed to implement and oversee national public health department accreditation • Beta Test: Deschutes County • PHAB works to promote and protect the health of the public by advancing the quality and performance of public health departments in the United States through national public health department accreditation.

5. Why Accreditation? • Identify performance improvement opportunities • Improve management • Develop leadership • Improve relationships with the community. • Encourage and stimulate quality and performance improvement in the health department • Stimulate greater accountability and transparency.

6. Benefits of Accreditation • Credibility, transparency, and accountability • Recognition of high performing health departments • Framework for effective planning • Culture of quality and performance improvement • Access to resources for improvement • Public health services aimed at improving health outcomes

7. Why Now? • Training & TA resources available to counties • Grant opportunities • Potential to become more competitive applicant for other funding opportunities • Potential for a stronger voice at the table in CCO conversations • Important to show what PH does as all these transitions occur. • Important to focus on efficiency and quality improvement in current economic environment.

8. Accreditation & the Work You Are Already Doing • 10 Essential Services of Public Health • Recognition for the work you are already doing • Shows what public health does • Minimum Standards

9. 10 Essential Services & 12 Domains

10. DOMAIN Domain Structure • Standard: required achievement • Measure: level required to meet standard • Documentation: shows the achievement www.phaboard.org

11. PHAB Standard Example

12. Accreditation Prerequisites • Community Health Assessment (CHA) • Community Health Improvement Plan (CHIP) • Agency Strategic Plan (SP)

13. Community Health Assessment (CHA) • Health status of the population, identify areas for health improvement, determine factors that contribute to health issues, and identify assets and resources that can be mobilized to address population health improvement. • Collaborative process of collecting and analyzing data and information for use in educating and mobilizing communities, developing priorities, garnering resources, and planning actions to improve the population’s health.

14. Community Health Improvement Plan (CHIP) • Long-term, systematic plan to address issues identified in the CHA. • Describe how the health department and the community it serves will work together to improve the health of the population of the jurisdiction that the health department serves (more comprehensive than the roles and responsibilities of the health department alone). • Community-driven, participatory planning process, stakeholder involvement.

15. Strategic Plan (SP) • Process for defining and determining an organization’s roles, priorities, and direction over three to five years. • Sets forth what an organization plans to achieve, how it will achieve it, and how it will know if it has achieved it. • Provides a guide for making decisions on allocating resources and on taking action to pursue strategies and priorities. • Focuses on the entire health department. Health department programs may have program-specific strategic plans that complement and support the health department’s organizational strategic plan.

16. 7 Steps to Accreditation

17. Preparing for Accreditation • Consider costs and payment, assign an Accreditation Coordinator, learn about process • Engage leadership and staff, form a team, develop a plan and timeline • Start Prerequisites • Gather documentation and score measures • Identify and Analyze strengths and weaknesses • Prioritize the problems • Implement Quality Improvement (Domain 9) • Institutionalize assessment and CQI processes

18. Documentation • Documentation will come from across all programs, important to know what this needs to look like: • Must be dated • No draft documents • Must be in effect and in use at the time that they are submitted to PHAB • Health departments are encouraged to provide narrative that describes how the submitted document relates to and meets the requirement (highlighting or text box encouraged)

19. Select & Organize Documentation • Gathering Documentation: • Gather documentation to show conformity to PHAB Standards and Measures • PHAB Standards and Measures Version 1.0 • National Public Health Department Accreditation Documentation Guidance

20. Analyzing Areas for Improvement • Analyzing areas for improvement uncovered by the self-study is an important step to developing a quality improvement process that will result in solutions.

21. Prioritizing Problems • Multiple problem areas that need to be addressed and with limited resources, time, and staff, an agency cannot begin to address all of them at once. • Prioritization Techniques

22. What is Quality Improvement? • QI is the use of a deliberate and defined process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. • It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes and other indicators of quality services or processes which achieve equity and improve the health of the community. Developed by the Accreditation Coalition Workgroup and approved by the Accreditation Coalition in June 2009

23. Why Quality Improvement? • Foundation of Accreditation • Focuses on efficiency and effectiveness • Demonstrates commitment to high quality services • Shows that we are good at what we do and always improving

24. QI in the context of accreditation QI is an important component of accreditation and of an effective, efficient HD Domain 9, interwoven throughout Prioritized component of accreditation for leadership Re-accreditation improve improve Accreditation improve Improving the public’s health through continuous Quality Improvement

25. Domain 9: Quality Improvement Domain 9: Evaluate and continuously improve processes, programs, and interventions Standard 9.1: Use a Performance Management System to Monitor Achievement of Organizational Objectives Standard 9.2: Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions

26. Implementing Quality Improvement • Likely that many, if not all, high-priority focus areas identified through step 4 can be addressed through QI processes • Form a QI Team • Include front line personnel and staff that are routinely involved with the chosen focus area as the QI cycle is implemented • Develop a team charter to provide the team with a clear and concise plan of action

27. Institutionalizing the Continuous Improvements • Reaccreditation process every five years, demonstrating improvement from the previous cycle • Accreditation is a cyclical process of continuous improvement • Goals of the QI project are met for the first selected priority area the agency moves forward with institutionalizing the change • As a next step, the agency can move on to address the next highest priorities using the PDCA cycle and eventually, undergo another agency self-study process • http://www.naccho.org/topics/infrastructure/accreditation/stories.cfm

28. National Resources • PHAB Resources • http://www.phaboard.org/accreditation-process/guide-to-national-public-health-accreditation/ • http://www.phaboard.org/accreditation-process/public-health-department-standards-and-measures/ • NACCHO Resources • http://www.naccho.org/topics/infrastructure/accreditation/preparing.cfm • http://www.naccho.org/topics/infrastructure/accreditation/exampledocumentation.cfm • RWJ Resources • http://www.rwjf.org/publichealth/accreditation.jsp

29. Thank you! Erin Mowlds erin@oregonclho.org 541-280-6400